Recipient Information

Note: An asterisk (*) means that the information is required

Last Name: Enter last name of the recipient.

• If the recipient has only one name, enter name in the last name field and leave the first name blank.

First Name: Enter first name of the recipient.

Middle Initial: Enter middle initial of the recipient.

• If the recipient does not have a middle initial, leave blank.

Mother's Maiden Name: Enter the mother's maiden name of the recipient.

• This field allows a minimum of 2 and a maximum of 20 alpha characters including hyphens.

Date of Birth: Enter date of birth of the recipient in the space provided using the following format: Month (MM)/ Day (DD)/ Year (CCYY). For example, January 7, 1950 would be entered as 01/07/1950.

Address: Enter residence address of the recipient. If homeless, enter the address where the recipient receives mail.

City: Enter name of the city in which the recipient lives or receives mail.

ZIP Code: Enter the ZIP code for the recipient’s residence or mailing address.

Phone Number: Enter the recipient’s telephone number, including area code.

• If the recipient has no telephone number, enter the telephone number of the recipient’s contact.

Are you Hispanic or Latino? Enter the recipient’s response to this question. Please encourage applicants to provide race and ethnicity information.

• Even if the recipient responds “Yes,” further race information is desired.

Select all that apply to you: Use the selection box to choose one (or more) race designation(s) that apply to the recipient. Press and hold CTRL key to select more than one race designation.

• If possible, avoid selecting "Unknown" for race. Complete race information is desired.

Asian – Select one: Use the drop-down box to select the sub-category of Asian if the recipient indicates that she is “Asian.”

Pacific Islander – Select one: Use the drop-down box to select the sub-category of Pacific Islander if the recipient indicates that she is “Pacific Islander.”

Meets CDP age criteria: Select this box if the recipient meets the program age criteria.

Meets CDP income and insurance criteria: Select this box if the recipient meets the program income and insurance criteria.

• File the forms used to validate that the recipient meets these criteria in the recipient’s medical record.

Signed CDP consent form: Select this box if the recipient has signed the program consent form.

• File the signed consent and eligibility forms in the recipient’s medical record.

Recipient referred for Breast and Cervical Cancer Treatment Program: Select this box only when recipeint has known current diagnosis of breast or cervical cancer.

Note: Save the data entered by clicking the “Submit New Recipient” or “Update Recipient Info” button at the bottom of the form. If the recipient is being recertified, this button will read “Recertify Recipient.”